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SMA-SGH SEMINARS ON MEDICAL ETHICS AND HEALTH LAW 2003
Dr Chin Jing Jih Chairman, SMA Ethics Committee Deputy Director, SMA Centre for Medical Ethics & Professionalism
What is medical ethics?
= social conventions [beliefs and practices] about right and wrong human conduct that are so widely shared that they form a stable community consensus
= a systematic reflection on and analysis of morality A generic term for various ways of understanding and examining the moral life.
What is MEDICAL ETHICS ?
Developed from the view that ethical problems from medicine can be resolved by applying principles of moral philosophy.
Objective – making choices in ethically significant matters in the practice of medicine
the practical and structured approach to assist physicians (and health care workers) in identifying, analysing and resolving ethical issues constructively in clinical medicine.
Role of MEDICAL ETHICS in daily clinical practice For those situations in which we already know what is right and what is wrong it should help us explain why the one choice is right and the other wrong For those situations in which it is not obvious what is right and what is wrong it should guide us to discover what is the right thing to do .
MEDICAL (HEALTH CARE) ETHICS : 3 LEVELS OF RELEVANCE Doctor-patient relationship Policies in health care institutions Health care policies in society .
Prevention of disease and injury Promotion and maintenance of health Relief of pain and suffering Care and cure of those with malady Avoidance of premature death Pursuit of a peaceful death . special supplement Nov-Dec 1996. Hasting Center Report.GOALS OF MEDICINE The goal of medicine: Setting new priorities.
WHAT MAKES THE MEDICAL PROFESSION UNIQUE? a service profession dedicated to the healing of patients. based on a fiduciary doctor-patient relationship an obligation for doctors do the utmost in caring for patients allows the sick to claim their right to humane and dignified care from doctors .
Looks mainly at due Process Establishes negative sanctions for ignoring the standard. Power resides primarily in the strength of reasoning. and include the praise or blame of colleagues or others. the legal cases have ethical relevance.generally non-coercive. what is legally permitted may not be ethically justifiable in a particular case .ETHICS & LAW: LAW Seeks to educate and to regulate by announcing a minimal standard of conduct. unaccompanied by state endorsement Because respecting law is an important moral duty. However. which has the power of official coercion ETHICS Extends beyond the law to prescribe desirable conduct and articulate ideas and virtues to which we should aspire Ethical sanctions.
Normative Theories of ethics Deontological theory Teleological theory Greek: deonto = duty Greek telos = end DUTY-BASED CONSEQUENT action > consequensces BASED ==> obligations and duties in the forms of rules and principles consequences ==> right or wrong right action = one which causes maximum beneficial results e. utilitarianism .g.
„4-Principle‟ Approach: NONMALEFICENCE = the obligation to avoid the causation of harm requires merely the omission of harm-causing activities .
„4-Principle‟ Approach: BENEFICENCE = the obligation to provide benefits and to balance benefits against risks requires positive steps to help others .
both for political life and for personal development .„4-Principle‟ Approach: RESPECT FOR AUTONOMY = the obligation to respect the decision-making capacities of autonomous activities rooted in the liberal western tradition of the importance of individual freedom.
„4-Principle‟ Approach: JUSTICE = obligations of fairness in the distribution of benefits and risks .
e. always binding unless they conflict with obligations expressed in another moral principle Balancing of the demands of the conflicting obligations which principle overrides in case of conflict depends on the particular context. i. which is likely to have unique features .„4-principle‟ Approach (Beauchamp. Childress) The principles are prima facie.
Childress) The exercise of judgement in circumstances of uncertainty is inevitable.„4-principle‟ Approach (Beauchamp. A justifiable infringement of a moral principle or rule must: – – be necessary in the circumstances in the sense that there are no morally preferable alternative actions that could be substituted be the least infringement possible .
4-BOX APPROACH CASE HISTORY [casuistic approach] Medical indications Quality of life Patient preference Contextual features recommendations .
What are goals of treatment? 4. What is patient‟s medical problem ? diagnosis? prognosis? 2. What are plans in case of therapeutic failure? In sum. What are probabilities of success? 5.MEDICAL INDICATIONS 1. Is problem acute? chronic? critical? emergent? reversible? 3. how can this patient be benefited by medical and nursing care. and how can harm be avoided? .
Tell me what you are thinking? .
and given consent? 3.g. understood. What has the patient expressed about preferences for treatment? 2. e. If incapacitated. is patient‟s right to choose being respected to extent possible in ethics and law ? .. Is patient mentally capable and legally competent? What is evidence of incapacity? 4. Has patient been informed of benefits and risks. why? In sum.PATIENT PREFERENCE 1. Is patient unwilling or unable to co-operate with medical treatment? If so. who is appropriate surrogate? Is surrogate using appropriate standards? 6. Has patient expressed prior preferences. Advance Directives? 5.
What are the prospects. mental. with or without treatment. and social deficits is patient likely to experience if treatment succeeds? 4. Any plan and rationale to forgo treatment? 6. Is patient‟s present or future condition such that continued life might be judged undesirable by them? 5. Are there biases that might prejudice provider‟s evaluation of patient‟s quality of life? 3. What plans for comfort and palliative care? .QUALITY OF LIFE 1. for a return to patient‟s normal life? 2. What physical.
CONTEXTUAL FEATURES 1. What are legal implications of treatment decisions? 8. Any provider or institutional conflict of interest? . Are there provider (physicians and nurses) issues that might influence treatment decisions? 3. Are there family issues that might influence treatment decisions? 2. Are there problems of allocation of resources? 7. cultural factors? 5. Is there any justification to breach confidentiality? 6. Are there religious. Are there financial and economic factors? 4. Is clinical research or teaching involved? 9.
Moral rules and principles are best appreciated in the specific context of the actual circumstances of a case. .4-BOX APPROACH A device for teaching and discussion User (health care providers + families) friendly vocabulary A practical review method to move a discussion of an ethical problem toward a resolution Begins with the factual features of a case. Principles and rules are referred to as they arise in the discussion of each box/topic.
No system of guidelines could reasonably anticipate the full range of conflicts to provide mechanical solutions or definitive procedures for decision-making about moral problems in medicine. Experience and sound judgement are indispensable allies .Facts + Principles Judgement No escape from the exercise of judgement in circumstances of uncertainty BUT not just any judgement will be acceptable.
are NOT necessary the only and most important goals of patients Judgements and decisions are frequently .value laden .role-dependent .influenced by self.CONFLICTS & DILEMMAS Treatment : effective + humane & dignified Medical goals from the perspectives of doctors.and other interests .
COMMON ETHICAL PROBLEMS IN HOSPITAL PRACTICE Patients‟ and/or families‟ demand for “everything be done” regardless of medical futility Patients‟ refusal of treatment / placement Family‟s insistent of withholding diagnosis Use of tube feeding in demented patients Issues related to informed consent Confidentiality issues Justice / Distribution issues .
COMMON PRETENDERS OF ETHICAL PROBLEMS Inappropriate medical indications Treatment options inadequately explored Communication problems Breakdown in therapeutic relationships due to bad outcomes Discharge problems Legal problems Assessment of decisional capacity of a patient Obtaining informed consent .
do no harm.CLINICAL ETHICS VERSUS RESEARCH ETHICS CLINICAL ETHICS RELATIONSHIP PRIMARY OBJECTIVE NONMALEFICENCE INTERVENTION CONSENT Doctor-patient Fiduciary therapeutic effect to benefit patient RESEARCH ETHICS Researcher-patient competing and conflicting interests Generalisable knowledge to benefit society “Above all.” Risk of harm always exists risk-benefit ratio Proven or established treatments Implied and verbal consent applies except for high risk treatment Experimental treatment clinical equipoise Full informed consent process and document except for minimal risk research .
1979)”] Nuremberg War Trials. Benficence assessment of benefits and risks 3. Respect for persons infromed consent 2. Justice patient selection . Tuskegee Experiment 1.The Belmont Report : Ethical Principles and Guidelines for the Protection of Human Subjects of Research [The National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research (April 18.
Clarifies complex issues Improves communication Offers options and/or specific recommendations Provides reassurance and guidance Ultimately improves patient care .ETHICS CONSULTATION SERVICE Assists hospital‟s health care professionals in the analysis and resolution of ethical issues encountered in daily clinical practice.
ETHICS CONSULTATION SERVICE NOT to takeover the duties or rights of individual doctors to make decisions NOT to interfere with treatment or management NOT to police the doctors NOT to provide legal immunity / coverage .
. sustainable and enjoyable part of our lives. ethical.The practice of medicine in a thoughtful. compassionate and effective manner helps to make doctoring a satisfying.